Rehabilitation and Recovery following Stroke

The CSBPR Rehabilitation and Recovery following Stroke module provides guidance to health professionals caring for people with stroke and is applicable to people with a range of impairments and limitations from very mild to very severe.  Stroke rehabilitation applies across the continuum of care from the early rehabilitation assessments soon after the stroke occurs, throughout the early recovery phase (usually the first 90 days) and continues beyond that to ensure that each individual achieves optimal recovery and is able to maintain and sustain recovery and minimize deterioration over time.  This applies across all functional domains, including physical, cognitive, psychological and social domains, and across a range of inpatient and community settings. People with stroke may move back and forth between different stages of care as their healthcare needs and situations change and it is important that ongoing rehabilitation needs to be reassessed and individual rehabilitation plans be updated at all transition points and when there is a change in health status.

For more information related to the Virtual Stroke Rehabilitation 7th Edition Interim Consensus Statement 2022, please view the statement.

With each update edition of the CSBPR  modules, the most current evidence on the included topics are reviewed by the writing group members and internal and external reviewers. Some recommendations from the previous edition have been continued unchanged, others have been modified to reflect updated evidence (either wording or evidence levels) or removed based on decisions of the writing group regarding ongoing relevance and or changes in supporting evidence. New recommendations be also been added to address emerging evidence and practice changes.

The Canadian Stroke Best Practice Recommendations (CSBPR) Rehabilitation and Recovery following Stroke 2019 Sixth Edition module supersedes all recommendations from the CSBPR Stroke Rehabilitation 2015 Fifth Edition module.

The 2019 update of the CSBPR Rehabilitation and Recovery following Stroke module reinforces the growing and changing body of research evidence available to guide assessment, diagnosis and management of stroke related impairments in the days, weeks and months following a stroke.

Highlights of the moderate and significant updates as well as new additions to the Rehabilitation and Recovery following Stroke module recommendations for 2019 include:

• New clinical considerations have been added to each section, acknowledging emerging therapies and consensus-based practices where there is a lack of sufficient evidence to qualify as a recommendations, yet users of CSBPR have requested some expert guidance on the topic.
• The module contents were reviewed by anew Community Consultation and Review Panel (CCRP), consisting of a group of people with stroke, their families, and caregivers. This group reviewed all modules immediately following the writing group’s review and edits, and provided personal experiences and context. Their inputs were received and integrated into appropriate sections throughout the module, such as the rationale, system implications, and resource sections throughout the module.
• New recommendations provided to address people who are unable to produce any voluntary muscle activity in the affected upper limb. These statements focus on compensatory techniques using the non-paretic arm and associated adaptive equipment to ensure basic activities of daily living.
• Updates on the recommendations on the use of slings stating that they are discouraged except for the flaccid stage. Previous recommendations described the use of slings as controversial.
• New recommendation added regarding taping of a hemiplegic shoulder to reduce pain.
• New recommendation added addressing the insufficient evidence for or against the use of compression garments (e.g. compression gloves) for hand edema. Additionally, for hand edema, a statement was added recommending elevation of the arm when at rest if possible.
• More detailed recommendations are provided on biofeedback to improve gait training and improve functional recovery.
• Increased detail on balance-related recommendations.
• Gait aid recommendations have been integrated into lower-limb gait training, balance, and aerobic training, rather than being a specific subheading of recommendations.
• Significant updates made to recommendations on visual perceptual deficits, including that limb activation and trunk rotation do not appear to be effective at improving neglect and that virtual reality and computer-based interventions for neglect are effective for improving visual perception and alleviating right-hemisphere bias.
• New recommendation added addressing augmentative alternative communication (e.g. tablets, electronic devices, alphabet boards) and other technology for patients with language and communication challenges.
• Rehabilitation approaches, therapies and interventions for topics related to life roles and community participation have been removed from this module. They are now contained in the Rehabilitation, Recovery and Community Participation module Part 2: Transitions and Community Participation module, to streamline information and reduce redundancy. These recommendations can be found here.

The detailed methodology and explanations for each of these steps in the development and dissemination of the CSBPR  is available in the Canadian Stroke Best Practice Recommendations Overview and Methodology manual available on the Canadian stroke best practices website at
https://www.strokebestpractices.ca/recommendations/overview-methods-and-knowledge-exchange

For Guideline Methodology of the Virtual Stroke Rehabilitation 7th Edition Interim Consensus Statement 2022, please view the statement.

Robert Teasell (First Author), Nancy M Salbach (Co-First Author) Nicole Acerra, Diana Bastasi, Sherri L Carter, Joyce Fung, Mary-Lou Halabi, Jocelyn Harris, Esther Kim, Andrea Noland, Sepideh Pooyania, Annie Rochette, Bridget D Stack, Erin Symcox, Debbie Timpson, Suja Varghese, and Sue Verrilli on behalf of the Rehabilitation and Recovery following Stroke Writing Group. Rehabilitation and Recovery Following Stroke module 2019. In M. Patrice Lindsay, Anita Mountain, Gord Gubitz, Dar Dowlatshahi, Leanne K Casaubon, Andrea de Jong and Eric E Smith (Editors) on behalf of the Canadian Stroke Best Practices Advisory Committee. Canadian Stroke Best Practice Recommendations, 2019; Ottawa, Ontario Canada: Heart and Stroke Foundation.

Comments

We invite comments, suggestions, and inquiries on the development and application of the CSBPR. Please forward comments to the Heart and Stroke Foundation’s Stroke Team at
strokebestpractices@heartandstroke.ca

Nancy M. Salbach, Anita Mountain, M. Patrice Lindsay (Corresponding author), Dylan Blacquiere, Rebecca McGuff, Norine Foley, Hélène Corriveau, Joyce Fung,  Natalie Gierman, Elizabeth Inness, Elizabeth Linkewich, Colleen O’Connell, Brodie Sakakibara,  Eric E. Smith,  Ada Tang,  Debbie Timpson,  Tina Vallentin, Katie White and Jennifer Yao (Senior Author); on Behalf of the Canadian Stroke Best Practice Recommendations Advisory Committee, in collaboration with the Canadian Stroke Consortium and the Canadian Partnership for Stroke Recovery. Canadian Stroke Best Practice Recommendations: Virtual Stroke Rehabilitation, Seventh Edition, 2022; Toronto, Ontario, Canada: Heart and Stroke Foundation. In M. Patrice Lindsay, Anita Mountain, Rebecca McGuff, and Eric E. Smith (Editors), on behalf of the Canadian Stroke Best Practices and Advisory Committee in collaboration with the Canadian Stroke Consortium and the Canadian Partnership for Stroke Recovery. Canadian Stroke Best Practice Recommendations, 7th edition; Heart and Stroke Foundation of Canada. 

Comments

We invite comments, suggestions, and inquiries on the development and application of the CSBPR. Please forward comments to the Heart and Stroke Foundation’s Stroke Team at strokebestpractices@heartandstroke.ca.

• Rehabilitation and Recovery following Stroke guideline publication in the International Journal of Stroke
• Writing Group Members
• Stroke Rehabilitation Definition and Considerations

A: Organization of a Stroke Rehabilitation System for Optimal Service Delivery

1.0 Initial Stroke Rehabilitation Assessment

• Box One: Eligibility and Admission Criteria for Stroke Rehabilitation
• Evidence Table and Reference List

2.0 Stroke Rehabilitation Unit Care

• 2.1 Stroke Rehabilitation Unit Care
• 2.2 Stroke Rehabilitation Team
• Evidence Table and Reference List

3.0 Delivery of Inpatient Stroke Rehabilitation

• Evidence Table and Reference List

4.0 Outpatient & In-Home Stroke Rehabilitation (including Early Supported Discharge)

• 4.1 Outpatient & In-Home Rehabilitation
• 4.2 Early Supported Discharge (ESD)
• Evidence Table and Reference List

B: Providing Stroke Rehabilitation to Address Physical, Functional, Cognitive and Emotional Issues to Maximize Participation in Usual Life Roles

5.0 Management of the Upper Extremity following Stroke

5.1 Management of the Upper Extremity Following Stroke – General Principles and Therapies 

• Evidence Table and Reference List

5.2 Range of Motion and Spasticity in the Shoulder, Arm and Hand

• Evidence Table and Reference List

5.3 Management of Shoulder Pain & Complex Regional Pain Syndrome (CRPS) following Stroke

• Evidence Table and Reference List

6.0 Management of the Lower Extremity following Stroke

6.1 Balance and Mobility

• Evidence Table and Reference List

6.2 Lower Limb Spasticity following Stroke

• Evidence Table and Reference List

6.3 Falls Prevention and Management

• Table 2: Suggested Screening/Assessment Tools for Risk of Falling Post Stroke
• Evidence Table and Reference List

7.0 Assessment and Management of Dysphagia and Malnutrition following Stroke

• 7.1 Dysphagia
• 7.2 Nutrition and Hydration
• Table 3: Suggested Swallow Screening and Assessment Tools
• Evidence Table and Reference List

8.0 Rehabilitation of Visual Perception Deficits

• Evidence Table and Reference List

9.0 Management of Central Pain

• Evidence Table and Reference List

10.0 Rehabilitation to Improve Language and Communication

• Table 4: Suggested Screening and Assessment Tools for Aphasia
• Evidence Table and Reference List

NEW 11.Virtual Stroke Rehabilitation 7th Edition Interim* Consensus Statement 2022

• Section 1 Access, eligibility, consent and privacy
• Section 2 Technology and planning
• Section 3 Training and competency
• Section 4 Assessment and service delivery
• Evidence Table and Reference List

*This interim Consensus Statement was undertaken to address the pandemic-related shift to virtual care. This consensus statement will be fully integrated into the Rehabilitation and Recovery following Stroke module when that module undergoes full review in the CSBPR update process.